[Muscle involvement of Stormorken's syndrome]

We described two patients, a mother and daughter, of Stormorken's syndrome. The syndrome is characterized clinically by autosomal dominant inheritance, congenital miosis, thrombocytopenia, asplenia and muscle weakness. Both patients had bleeding tendency, ichthyosis of arms, and muscle weakness. The daughter additionally had short stature (146 cm), low body weight (32 kg) and muscle cramp. Neurological findings of the patients included migraine-like headache, cognitive dysfunction, limitation of upward and lateral gaze, and amydriasis. Femoral muscle MRI of the daughter demonstrated decreased volume with patchy high intensity areas in the hamstrings. A muscle biopsy from the daughter showed myogenic changes with muscle fiber necrosis and regeneration, variation in fiber size, tubular aggregates in approximately 5% of fibers, and fibrous tissue proliferation. Dystrophin, dystrophin-associated proteins and dysferlin were normally expressed. Although both patients had elevated creatine kinase levels and generalized muscle wasting, muscle weakness was mild with slow progression. A certain membrane defect in the platelet and muscle fiber might be responsible for the pathogenesis of this syndrome.

[A case of intracerebral and subarachnoid hemorrhage of unknown origin with preceding headache]

We report a case of a 31-year-old female with multiple intracerebral hemorrhage and subarachnoid hemorrhage. She presented with headache one week before hemorrhage, and a CT scan performed at that time showed no abnormal findings. Neurological examination on admission revealed mild disturbance of consciousness, papilledema, and mild left hemiparesis. CT scans demonstrated intracerebral hemorrhage in the right caudate head and left frontal subcortex, and diffuse subarachnoid hemorrhage. Cerebral angiogram and laboratory examination revealed no abnormal findings. Erythrocyte sedimentation rate, C reactive protein and antiphospholipid antibody were within normal ranges. The patient underwent removal of hematoma by craniotomy. One week after the operation, a subcutaneous hematoma in the area of the craniotomy was found. Cerebral angiography demonstrated an aneurysm of the right superficial temporal artery, which was remote from the craniotomy. This aneurysm was surgically removed and examined. Histopathological examination revealed the presence of a pseudoaneurysm but no inflammation. Although primary angitis of the central nervous system was suspected to be the cause of this disease, a definite diagnosis could not be obtained.

Increased band 3 protein aggregation and anti-band 3 binding of erythrocyte membranes on treatment with sesamol

The influence of sesamol, an antioxidant in processed sesame oil, on oxidative modification of human erythrocyte membrane proteins was investigated. Human erythrocytes were incubated with sesamol at various concentrations up to 10 mM at 37 degrees C for 1 h. The amounts of hemoglobin bound to the membranes and detergent C12E8-insoluble membrane protein aggregates were increased as the concentration of sesamol increased. Western blot analysis indicated that aggregates of band 3 protein were increased by the treatment. Binding of anti-band 3 antibody to the erythrocytes was increased by the treatment. Isolated cell membranes were incubated with sesamol similarly. Aggregates of band 3 protein were also increased, indicating that the band 3 protein aggregation was little affected by hemoglobin bound to the membranes. Aggregation of band 3 protein in the treatment of isolated cell membranes was partially prevented when the treatment was conducted under anaerobic conditions, suggesting that augmentation of the protein aggregation by sesamol involved both oxygen-dependent and oxygen-independent pathways. Among phenolics, sesamol showed a distinctive feature to increase band 3 protein aggregation in erythrocyte membranes and to enhance anti-band 3 binding to erythrocytes.

Factors that predict intrahepatic recurrence of hepatocellular carcinoma in 81 patients initially treated by percutaneous ethanol injection

BACKGROUND

In Japan, where liver transplantation has not been used to treat patients with hepatocellular carcinoma (HCC), percutaneous ethanol injection (PEI) has been employed for those with small HCCs that are not amenable to surgical resection. In the current study, the authors evaluated PEI as a treatment for HCC patients by studying recurrence rates and survival after treatment. They then examined the clinicopathologic factors that predicted patterns of local and distant intrahepatic recurrence.

METHODS

For 81 patients who underwent PEI as initial therapy between 1990 and 1997, the cumulative recurrence and survival rates and their correlations with 16 clinicopathologic factors were studied using the Kaplan-Meier method.

RESULTS

The 3-year overall cumulative rates of intrahepatic recurrence and survival were 81% and 84%, respectively. At the end of the observation period, intrahepatic recurrence was detected in 56 patients (69%). In 21 (38%) of 56 patients, local recurrences were significantly associated with earlier stages of underlying cirrhosis, decreased indocyanine green retention at 15 minutes (ICG R15), larger tumor size, and histologically advanced tumor grade. Distant intrahepatic recurrence was also significantly associated with liver function and ICG R15.

CONCLUSIONS

PEI is most effective as the initial treatment for patients with well-differentiated HCC when the tumor is less than 15 mm in greatest dimension. However, local recurrence depends predominantly on the biologic characteristics of the tumor, regardless of the efficacy of PEI. Surgical resection of HCC should be considered, especially for patients with mild liver dysfunction.

Factors that predict intrahepatic recurrence of hepatocellular carcinoma in 81 patients initially treated by percutaneous ethanol injection

BACKGROUND

In Japan, where liver transplantation has not been used to treat patients with hepatocellular carcinoma (HCC), percutaneous ethanol injection (PEI) has been employed for those with small HCCs that are not amenable to surgical resection. In the current study, the authors evaluated PEI as a treatment for HCC patients by studying recurrence rates and survival after treatment. They then examined the clinicopathologic factors that predicted patterns of local and distant intrahepatic recurrence.

METHODS

For 81 patients who underwent PEI as initial therapy between 1990 and 1997, the cumulative recurrence and survival rates and their correlations with 16 clinicopathologic factors were studied using the Kaplan-Meier method.

RESULTS

The 3-year overall cumulative rates of intrahepatic recurrence and survival were 81% and 84%, respectively. At the end of the observation period, intrahepatic recurrence was detected in 56 patients (69%). In 21 (38%) of 56 patients, local recurrences were significantly associated with earlier stages of underlying cirrhosis, decreased indocyanine green retention at 15 minutes (ICG R15), larger tumor size, and histologically advanced tumor grade. Distant intrahepatic recurrence was also significantly associated with liver function and ICG R15.

CONCLUSIONS

PEI is most effective as the initial treatment for patients with well-differentiated HCC when the tumor is less than 15 mm in greatest dimension. However, local recurrence depends predominantly on the biologic characteristics of the tumor, regardless of the efficacy of PEI. Surgical resection of HCC should be considered, especially for patients with mild liver dysfunction.

Unidirectional olfactory hallucination associated with ipsilateral unruptured intracranial aneurysm

PURPOSE

We describe a patient with complex partial seizure with unidirectional olfactory aura associated with ipsilateral unruptured aneurysm.

METHODS AND RESULTS

The patient felt a sweet pleasant smell coming from behind her right side every time before the attack. Cranial magnetic resonance imaging (MRI) and three-dimensional computed tomography (CT) angiography revealed a large aneurysm at the bifurcation of the right middle cerebral artery and compression of the right orbitofrontal cortex. Small spikes were recorded from the right orbitofrontal and superior temporal gyri and from the uncus by the cortical electrodes during clipping of the aneurysm.

CONCLUSIONS

The orbitofrontal cortex may have a function related to the ipsilateral directional olfactory sensation.

Using Gaussian-like input rate function in the two-compartment model. Formulation and application to analysis of didanosine plasma concentration in two Japanese hemophiliacs

We used a time-dependent input rate function in the two-compartment model to simulate drug plasma concentrations after an oral administration. The input rate term has a Gaussian-like structure with two parameters, time to maximum absorption rate (tm) and measure of the duration of the absorption process (s). This structure corresponds to the scenario in which the absorption rate of the drug into the central compartment changes unimodally with respect to time after administration with a single peak at time tm. We demonstrate the applicability of this formulation in the simulation of plasma concentration of didanosine after oral administration in two Japanese hemophiliacs. We found that we were able to simulate the time courses of the didanosine plasma concentrations in both patients using the theoretical equation with the input term included, and that we were able to determine the six parameters in the equation by the least squares estimation. Pharmacokinetic values derived from the best-fit curve were almost comparable to those reported in other literature except that the Cmax and AUC0-infinity seemed to be slightly higher than those reported elsewhere. Although we are unable to verify the accuracy of this formulation because of the lack of sufficient Japanese data, we are able to demonstrate its efficacy and convenience in the application presented here.

Consecutive in vivo measurement of nitric oxide in transient forebrain ischemic rat under normothermia and hypothermia

The effects of hypothermia on production of nitric oxide (NO) in ischemic brain were investigated by using in vivo microdialysis. Male Wistar rats were randomly divided into three groups; saline-treated normothermic group (37 degreesC, n=6), 30 mg/kg N-nitro-l-arginine methyl ester(l-NAME)-treated normothermic group (n=6), and saline-treated hypothermic group (30 degreesC, n=6). Transient forebrain ischemia was produced by bilateral common carotid artery occlusion combined with hypotension (MABP=50 mmHg). Saline-treated normothermic animals resulted in a reduction of LCBF to 9% of baseline. Saline-treated hypothermic rats revealed the similar changes of LCBF. In contrast, l-NAME administration reduced the basal CBF to 85% of saline-treated group and to 8% after ischemia. NO products were decreased during ischemia and transiently increased after reperfusion in saline-treated groups. However, the increase of NO products after reperfusion was less significant in the hypothermia. l-NAME-treated group showed a constant reduction of NO production during ischemia and after reperfusion.

Hypothermia attenuates hyperglycolysis in the periphery of ischemic core in rat brain

Hypothermia has proven to be neuroprotective against ischemic brain injury. However, the exact mechanism has not yet been fully understood. In this study, we investigated the effects of hypothermia on cerebral glucose metabolism and blood flow in focal ischemic rats. Rats were divided into normothermic (37+/-0.5 degrees C) and hypothermic (30+/-0.5 degrees C) groups. Focal cerebral ischemia was induced by middle cerebral and ipsilateral common carotid arteries occlusion. Two hours after ischemia, autoradiographic studies of 2-deoxyglucose and iodoantipyrine were performed to measure local cerebral glucose utilization (LCGU) and cerebral blood flow. LCGU in the ischemic core was excessively reduced in both groups. However, a marked increase in LCGU was observed in the boundary zone of the ischemic core in normothermic rats. On the other hand, hyperglycolysis in the boundary zone of the ischemic core was suppressed in hypothermia. This attenuation of hyperglycolysis might be closely related to survival of the ischemic penumbra in hypothermia.

[The effect of hippocampal dentate granule cell lesions upon the limbic seizure model of rats]

The purpose of this study was to determine the role of dentate granule cells upon limbic seizure of Wistar rat caused by unilateral intra-amygdaloid administration of kainic acid (KA). Stereotactic surgery was performed in Wistar rats and stainless steel injection chemitorode was inserted in the left amygdala. Left dentate granule cells lesion were induced by microinjection of colchicine. The rats obtained recovery period for 7 days, postoperatively. The rats were divided into two groups. One group were used for observation of symptoms and electroencephalographic findings during the limbic seizure for 6 hours after the KA injection. Another group was processed for measuring local cerebral glucose utilization (LCGU) during limbic seizure status. The histological study demonstrated a selective loss of dentate granule cells in the left hippocampus 7 days after the colchicine injection. After the KA injection, initiation of the spike discharge was significantly retarded not only in the hippocampus (from 6.01 min. to 37.25 min.) but also in the amygdala (from 2.96 min. to 10.8 min.). Progression, frequency and intensity of the KA induced seizures were also inhibited by the colchicine-induced dentate granule cells lesion. During limbic seizure status, LCGU obtained by 14C-deoxyglucose autoradiography were significantly decreased not only in the hippocampus but also in the amygdala on the site of KA injection. These data suggest that hippocampal dentate granule cells play an important role on initiation and progression of the KA induced limbic seizure. The result suggested that there was an acceleration mechanism of the limbic seizure between amygdala and hippocampus.

Temporary arterial occlusion during anterior communicating or anterior cerebral artery aneurysm operation under tibial nerve somatosensory evoked potential monitoring

BACKGROUND

Median nerve somatosensory evoked potentials (SEP) have been used as an indicator of cerebral ischemia in the territory of the middle cerebral artery. This study was designed to examine whether tibial nerve SEPs are a useful technique for detecting ischemia in the territory of the anterior cerebral artery (ACA) during aneurysm surgery.

METHODS

Tibial nerve SEP monitoring was employed in 15 patients who underwent temporary arterial occlusion during surgery for aneurysms of the anterior communicating artery (ACoA) or ACA. To evaluate tibial nerve SEPs, the data after anesthesia induction but before the start of surgery were used as the control and a more than 50% decrease in the amplitude of P40-N50 was regarded as a significant change.

RESULTS

Changes in SEP were recognized in 11 of these 15 patients. Unilateral A1 occlusion resulted in SEP changes in 4/7, while bilateral A1 interruption caused changes in 6/8 of the patient group. The allowable duration of interruption of the ACA cannot be determined by A1 dominance or the extent of development of the ACoA that can be recognized by angiography. The significance of the collateral circulation via the leptomeninges was indicated. Following the release of the occlusion, SEPs were restored to the control level in all patients and no new motor deficits were found.

CONCLUSIONS

It was concluded that tibial nerve SEP monitoring is a useful system to determine the extent of cerebral ischemia of the ACA territory during temporary arterial occlusion associated with surgery for aneurysms involving the ACA system.

Hypothermia attenuates the activation of protein kinase C in focal ischemic rat brain: dual autoradiographic study of [3H]phorbol 12,13-dibutyrate and iodo[14C]antipyrine

Using phorbol 12,13-dibutyrate (PDBu) autoradiography, we investigated the effect of hypothermia or protein kinase C (PKC) activation in rat brain 2 h after focal ischemia. In normothermia, a significant increase of PDBu binding was observed in ischemic brain. Hypothermia suppressed the increase of PDBu binding in degree and extent. These observations suggest that intraischemic hypothermia attenuates the activation of PKC, and this may in part be participate in the protective effect of hypothermia.

Dumbbell-shaped jugular foramen schwannoma

The authors present a case of dumbbell-shaped schwannoma arising from the vagus nerve. A 40-year-old woman was admitted with a 3-month history of hearing loss on the left ear without vertigo. Neuro-otological examinations revealed retrocochlear deafness with abnormal left vestibular function. Magnetic resonance imaging revealed a dumbbell-shaped tumor of the jugular foramen. The tumor was removed through a cervical-transmastoid approach using Cavitoron ultrasonic surgical aspiration. Two months after the operation, the patient's hearing loss had improved, although she still had some aspiration of saliva and hoarseness.

Suppression of acute experimental allergic encephalomyelitis in Lewis rats with a mycophenolic acid derivative

Oral administration of ethyl O-[N-(p-carboxyphenyl-carbamoyl]-mycophenolate (CAM), a derivative of mycophenolic acid (MPA) and an inosine monophosphate dehydrogenase inhibitor, dose-dependently suppressed acute experimental allergic encephalomyelitis in Lewis rats without exerting any serious adverse effects. A daily dose of 50 mg/kg of CAM almost completely abolished both the clinical disease and the inflammation in the CNS. In the CAM-treated rats, a weight loss and fluctuations of peripheral lymphocyte subsets were minimized. The CAM treatment was effective when started at the time of sensitization but ineffective when deferred till day 10. Furthermore, CAM reduced the percentage of CD4+CD45RC- cells in the peripheral blood. The only detectable adverse effect was moderate anemia but it was rapidly improved after withdrawal of the drug. This drug could be a useful adjunct for the long-term immunosuppressive therapy for inflammatory diseases of the CNS.

Dissociation of 99mTc-ECD and 99mTc-HMPAO distributions in herpes simplex encephalitis

In herpes simplex encephalitis (HSE), the authors noted an evident dissociation between the 99mTc-ethyl cysteinate dimer (ECD) and 99mTc-d,l-hexamethyl-propylene-amine oxime (HMPAO) single photon emission computed tomographies (SPECTs). The patient was a 5-year-old boy with diffuse type of pontine glioma, which was treated with hyperfractionated radiotherapy. Two weeks after the completion of radiation therapy, a lesion suggesting that of HSE was noted in the right fronto-temporal region on magnetic resonance images. 99mTc-HMPAO SPECT showed an increased accumulation of the tracer in this lesion. On the 99mTc-ECD dynamic SPECT, an exaggerated accumulation of the tracer was noted within 80 s of administration, followed by a rapid drop in the accumulation, resulting in a low accumulation in 10 min. It was assumed that this dissociation was due to the different mechanisms to trap HMPAO and ECD in the brain tissue.

Aneurysms located at the horizontal segment of the anterior cerebral artery or the middle cerebral artery

Aneurysms at the horizontal segment of the middle cerebral artery or anterior cerebral artery are relatively rare. The characteristics of 13 cases were analyzed retrospectively. Six of the 13 cases had multiple aneurysms, nine had aneurysmal rupture, and three of these nine were complicated by intracerebral hematoma. Neck clipping of the aneurysm was performed in 11 cases and four developed new cerebral infarction in the territory of the perforating arteries. Overall mortality and morbidity was 15% and 38%, respectively. The outcome for patients with aneurysms at these sites was evidently poorer than for those with aneurysms at other sites.

Protein kinase C in focal ischemic rat brain: dual autoradiographic analysis of [14C]iodoantipyrine (IAP) and [3H]phorbol-12,13-dibutyrate (PDBu)

Protein kinase C (PKC) activity was measured in rat brain with 2 h of middle cerebral artery (MCA) and common carotid artery (CCA) occlusion, using dual autoradiography of [14C]iodoantipyrine (IAP) and [3H]phorbol-12,13-dibutyrate (PDBu). In the ischemic brain, it required more than 120 min of incubation to obtain a plateau in PDBu binding. In contrast, the binding of PDBu in non-ischemic brain reached a plateau with incubation for 60 min. This delay of PDBu binding in the ischemic brain suggests that the affinity of this ligand is reduced due to a change in structure of the cell membrane caused by ischemia. PDBu binding in the ischemic brain increased significantly compared to the non-ischemic brain. This finding provides further evidence that excessive activation of PKC in the ischemic brain may play an important role in ischemic neuronal damage.

Glial cyst in the thalamus with intracystic hemorrhage--case report

A 19-year-old female presented with an unusual glial cyst of the thalamus that caused development of acute hydrocephalus due to hemorrhage and manifested as headache and fainting attacks. Computed tomography showed a large cystic mass lesion in the left thalamus with intracystic hemorrhage. The cyst was subtotally removed. Microscopic examination revealed mild gliosis with marked hemosiderin deposits. The inner surface of the cystic wall lacked an epithelial lining. The diagnosis was glial cyst. Magnetic resonance (MR) imaging 2 months after surgery showed a residual cyst in the left thalamus. However, after 12 months she was asymptomatic, neurologically intact, and MR imaging showed no regrowth of the cyst. Treatment of glial cyst must provide sufficient communication between the cyst and the cerebral ventricles rather than attempt total removal of the cyst, which may present a considerable challenge.

Sequential changes in cerebrovascular reserve capacity in three-vessel occlusion rats

To understand the pathophysiology of hemodynamic compromise, we evaluated the cerebrovascular reserve capacity of a cerebral hemisphere in rats with 3-vessel occlusion (3VO). The bilateral vertebral and left common carotid arteries were occluded in Wistar rats. Sequential changes in local cerebral blood flow (LCBF) and local cerebral plasma volume (LCPV) were measured by [14C]iodoantipyrine and [14C]dextran autoradiography, respectively. There was no significant difference in LCBF between 3VO and control rats at rest. After acetazolamide administration, however, an increase of LCBF in the left hemisphere was less significant compared to that in the right side in the 3VO rats. The left and right ratio was 0.67 +/- 0.15 (P < 0.05) in the parietal cortex and 0.70 +/- 0.10 (P < 0.01) in the caudate nucleus. This asymmetrical response to acetazolamide administration gradually corrected by 7 days after 3VO. A significant increase of the LCPV in the ischemic side was observed between day 0 and the 5th day. The 3VO rat is a useful model for studies on the pathophysiology of a hemodynamically compromised state.

[Familial multiple cavernous angioma in the brain and spinal cord]

We reported two patients from the same family underwent operation for neurological symptoms due to vascular lesions that were proved on pathological examination to be cavernous angiomas. Case 1, a 64-year-old woman was admitted to our hospital because of paraparesis. MRI revealed a mass lesion with high signal intensity in T1 and T2 weighted images at T3-4 level. Complete excision was carried out and diagnosis of cavernous angioma was made. Three years later, she experienced a mild headache and dizziness. CT scan demonstrated a subcortical hematoma in the right frontal lobe. Postoperative pathological diagnosis was cavernous angioma. Case 2, a 65-year-old woman (younger sister of case 1) was operated for the tumor of spinal cord, and diagnosed as a cavernous angioma. Two years later, she developed diplopia and ataxic gait. MRI showed multiple cavernous angioma in the brain including pons. Pontine lesion which was responsible for this episode was removed, and diagnosis was a cavernous angioma histopathologically.